Christine Clegg, 79, died after suffering a traumatic brain injury following a fall at Kesteven Grange Care Home in Hull. Assistant coroner Sally Robinson found that the severity of the injury was downplayed during an emergency call, preventing the patient from receiving immediate clinical attention.
The 'bump on the head' that masked a subdural haemorrhage
The incident occurred in June 2025 when Christine Clegg was discovered on the floor by a staff member at Kesteven Grange Care Home in Hull, East Yorkshire. According to the report, the carer who discovered Mrs. Clegg contacted the 111 service and informed the operator that the resident had "put herself on the floor" and had a "bump on her head."
This characterization of the event proved catastrophic. While the initial report suggested a minor incident, Mrs. Clegg was actually suffering from a traumatic subdural haemorrhage. As reported by the coroner, the patient's condition deteriorated over several days, eventually leading to a hospital admission where she passed away.
How the 111 'scratches and grazes' script failed Christine Clegg
The failure in care was compounded by the rigid nature of the 111 triage system. Call operators utilize specific scripts based on the information provided by the caller; in this instance, the operator used the pathway intended for "scratches, grazes or minor wounds" because of the biased information provided by the Kesteven Grange Care Home staff.
Had the operator been informed of a more serious head injury, the protocol would have shifted. The report says that if the "head, facial or neck injury" script had been employed, the system would have mandated that the carers speak with a clinician regardless of the subsequent answers provided.. Instead, the call concluded with only basic first aid instructions and no clinical intervention.
Sally Robinson's demand for NHS Pathways protocol changes
Assistant coroner Sally Robinson has issued a prevention of future deaths report to address this systemic vulnerability.. The report has been sent to both NHS Pathways and the Yorkshire Ambulance Service NHS Trust, with a specific directive to remove all head injuries from the "scratches , grazes and nicks" script.
By excluding injuries above the neck from the minor wounds pathway, Ms. Robinson argues that the risk of providing only basic first aid for potentially fatal head trauma is eliminated. This change would ensure that any reported head injury automatically triggers a requirement for professional clinician advice.
The gap between Kesteven Grange staff reports and clinical reality
A critical point of contention in the inquest was the discrepancy between the staff's account and the actual events. while the 111 operator was told that Christine Clegg had "placed herself on the floor," the coroner found that she had actually fallen from a bed, and that the head injury was actively bleeding at the time of the call.
This raises urgent questions regarding why the Kesteven Grange Care Home staff provided biased information to emergency services. It remains unclear whether this was a result of poor training, a misunderstanding of the injury's severity, or a deliberate attempt to minimize the incident. While the coroner has highlighted these failures, Kesteven Grange Care Home has yet to provide a public comment on the findings.
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